Pre-Medical Bridge Program - Formstack

Pre-Medical Post-Baccalaureate

2910 Prospect Park Drive, Rancho Cordova CA 95670

Application Instructions

Application must be typed and completed in full to qualify for a review. Application materials will not be returned. Please make a copy for your own records.

Email is the primary means of communication for applying to the Pre-Medical Post-Baccalaureate Program. Please be sure the email address you provide is correct and will accept email from admissions.chs@cnsu.edu. In order to protect your privacy, your email address will not be shared with a third party.

If you need disability-related accommodations to complete your application, please email us at admissions.chs@cnsu.edu.

U.S. Citizenship*

I am a Legal Permanent Resident I am a Non-resident Alien I am a U.S. Citizen

Have you already applied to the College of Medicine at California Northstate University?*

Yes No

Please select start date of the Pre-Medical Post-Baccalaureate (PMPB) program:*

AMCAS ID*

I will have official transcripts from all institutions attended sent to:

California Northstate University
College of Health Sciences
PMPB Program
9700 West Taron Drive
Elk Grove, CA 95757

Have you taken the MCAT?*

Yes No

Please send MCAT scores to:

California Northstate University
College of Health Sciences
PMPB Program
9700 West Taron Drive
Elk Grove, CA 95757

APPLICATION FORM

Legal Last Name*

First Name*

Middle Name

Suffix

Social Security Number

(If you don’t have a Social Security Number, leave the box blank)

Other names you use or have used

First Name

Middle Name (optional)

Last Name

Suffix (optional)

Current (Mailing) Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Permanent Address, if different from current address

Address Line 1

Address Line 2

City

State

ZIP Code

Country

County of

County of

Email Address*

Cell Phone Number

Home Phone Number

*To conform to federal regulations, California Northstate University must collect aggregated student demographic information for external reporting. This information will not affect any student’s application for admission.

Sex/Gender*

Male Female

Other:

(please specify, optional)

Date of Birth*

Place of Birth (City, State or Country)*

Ethnicity choose one (Optional)

Hispanic/Latino Not Hispanic/Latino

please specify, optional

Race (optional): The U.S. Census identifies the following races. Mark one or more categories that are appropriate to you.

American Indian or Alaska Native (please specify tribe below) Asian (please specify below) Black or African American Native Hawaiian or other Pacific Islander (please specify below) White

please specify, optional

If California Northstate University is asked to report ONLY ONE race/ethnicity description for you, please choose the ONE category below that you want us to report.*

Marital Status*

How did you hear about the Pre-Medical Post-Baccalaureate?*

CNU College of Medicine CNU College of Pharmacy CNU College of Health Sciences CNU website Social media Family or friend

Other:

Waiver

I authorize California Northstate University College of Medicine officials to release, or otherwise allow for inspection, copying or other disclosure, including discussion of, any and all education records to or with California Northstate University College of Health Sciences for the purpose of admission to the Pre-Medical Post-Baccalaureate.

This authorization does not permit disclosure of these records to any other persons or entities without my written consent unless specifically allowed under the Family Educational Rights and Privacy Act. I understand I may revoke this authorization at any time by a subsequent signed writing.

A photocopy or facsimile of the authorization and release will be valid as an original hereof, even though the said photocopy or facsimile does not contain my original signature.

Certification

I certify that I have read all of the instructions and I have answered all of the questions completely and truthfully. I understand misrepresentation of any portion of this application, including supporting credentials and documents, may be cause for canceling my admission or financial award. I also understand all credentials and documents I submit become the property of California Northstate University.

I have read and agree to the Waiver and Certification*

Yes

I have made the $100 PayPal payment*

Yes

Signature of applicant*

Use your mouse or finger to draw your signature above

Date*

Nondiscrimination: California Northstate University (CNU) is committed to cultivating a diverse educational community that values the inherent worth of every person within a climate of mutual respect. The University believes human diversity enhances and enriches the quality of our academic programs. CNU offers equal opportunity in education and employment and does not discriminate on the basis of race, color, creed, religion, national origin, ethnicity, gender, age, sexual orientation, political affiliation, veteran status, or disability.

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